Nalini Pather, Scientia Education Academy Fellow

Title: Immersive Learning, an evidence-based approach

Led by: Nalini Pather and Nicolette Birbara

Keywords: virtual reality, cognitive load theory, cognitive theory of multimedia learning, physical fidelity, prior knowledge, prior university experience, delivery modality, innovative design 

Introduction 

Immersive technologies such as virtual and augmented reality are becoming increasingly popular in higher education to develop virtual learning resources (VLRs).  In medical education these can be more practical and accessible than traditional resources.  However, if VLRs are going to be widely integrated into mainstream education, it is important that they foster effective learning.  Therefore, this project aimed to evaluate the impact of VLRs on the learner and learning in order to develop guidelines for the instructional design of VLRs for anatomy education, grounding these within cognitive load theory (CLT) and the cognitive theory of multimedia learning (CTML). 

The principles in the CTML (Mayer, 2009) as well as principles based on CLT (van Merrienboer & Sweller, 2010) may not be entirely catered towards the design of VLRs.  The most appropriate instructional design principles for VLRs need to consider other factors that are more specific to the characteristics and capabilities of immersive technologies.   

The overarching aim of this project was to develop guidelines for instructional design using immersive technologies for medical education. More specifically, the frameworks in this study are grounded in cognitive learning theories through an investigation of the cognitive load imposed by immersive technologies.   

Theoretical Background 

With advances in three-dimensional (3D) modelling, computer graphics and immersive technologies such as virtual reality (VR), it has become possible to simulate reality by creating virtual representations of real objects and environments.  The term “fidelity” is commonly used when describing such real-world simulations and refers to their degree of realism (Finan et al., 2012), or the exactness with which these real objects and environments are reproduced.  This can be considered in an “engineering” or “physical” sense relating to the appearance of the simulation, and in a “psychological” or “functional” sense relating to the behaviour of the simulation, a concept first introduced by Miller (1954).  In a medical context, realism accounts for the anatomical accuracy of a simulation and for surgical and procedural simulators, this would include how accurately these resemble both tissue texture and technical skills required for the task (Sarmah et al., 2017), therefore encompassing elements of both physical and psychological fidelity.  The use of real-world simulations can be highly useful in education to create virtual learning resources (VLRs), as it may not always be possible to deliver real-world learning experiences in a physical environment, for example when there is a high risk of danger  or when resources to support face-to-face training are limited. 

When the primary purpose is knowledge or skill transfer, VLRs could be created with either a high or a low level of fidelity.  The level of VLR fidelity required to be educationally effective is related to the context within which it is to be used.  In industrial applications such as mining, for example, where there is a high-risk element, it may be important to exactly replicate the working environment so that training can be efficient and scenario-based.  In the development of a VR mine safety training resource, Filigenzi et al. (2000) appropriately used real mine maps to accurately re-create mine geometry, allowing evacuation routes to be practised as realistically as possible and customising the user interface specifically for mining.  Fidelity was also a factor in the design of a prototype simulator by Zeltzer and Pioch (1996) to train submarine navigation officers.  They believed that specific components such as range markers, turning aids and channel buoys would be essential to accurately depict and therefore effectively support training for the task required.  However, they adopted a “selective fidelity” approach when designing each of the elements to include features that directly influenced task performance while ignoring insignificant features.  This demonstrates that fidelity can be refined to suit the specific purpose of the VLR. 

While a level of fidelity may prove useful in some contexts, in medical education it is somewhat unclear whether fidelity is required for VLRs to be effective and how selective it should be.   

The science of instruction is grounded in learning theories and educational psychology research has given rise to four major learning theories – association theory, information processing theory, metacognitive theory and social constructivist theory (summarized by Terrell, 2006).  These have shifted over time from a behavioural model (association theory) to a cognitive model (information processing, metacognitive and social constructivist theories) which encompasses learners themselves rather than simply the learning process (Terrel, 2006).  Learning theories under this cognitive model are appropriate for guiding instruction in disciplines involving large amounts of complex information, as they provide an insight into human cognitive architecture and processes and examine how this can be utilised most efficiently to learn.   

Khalil and Elkhider (2016) state that the predominant cognitive learning theory in educational psychology is the information processing theory, which forms the basis of John Sweller’s cognitive load theory (CLT) (Sweller, 1988, 1994; Sweller et al., 1998).  Cognitive load refers to the amount of mental effort being used by working memory, which is the part of memory involved in processing information.  According to CLT there are three components of cognitive load – intrinsic load, which is related to the inherent complexity of the information being learnt; extraneous load, which is related to the delivery of this information; and germane load, which is associated with the mental resources required to process the information and encode it to long-term memory (Sweller et al., 1998; van Merrienboer & Sweller, 2010).  CLT is centred around the idea that working memory has a limited capacity and if the combination of the three components of cognitive load exceeds this capacity, this leads to cognitive overload (van Merrienboer & Sweller, 2010).  Therefore, CLT and design principles based on it are concerned with aligning the delivery of learning content with the limitations of working memory by managing intrinsic load, decreasing extraneous load and optimising germane load (van Merrienboer & Sweller, 2010).  Decreasing extraneous load increases germane load by dedicating more working memory resources to processing the learning content itself rather than its delivery. 

Cognitive load is traditionally measured using subjective tools such as the Paas mental effort rating scale (Paas, 1992) and the National Aeronautics and Space Administration task load index (NASA-TLX) (Hart & Staveland, 1988).  In anatomy education, Kucuk et al. (2016) used the Paas mental effort rating scale to measure cognitive load when learning neuroanatomy using augmented reality (AR) compared to two-dimensional (2D) pictures and text, and Foo et al. (2013) used the NASA-TLX to compare the mental workload experienced when locating anatomical structures in 2D compared to three-dimensional (3D) views.  While the Paas mental effort rating scale is a single nine-point scale, the NASA-TLX accounts for different components of workload and allows for an overall workload score to be calculated based on these components.  However, it still only provides a “snapshot” of the workload experienced at a point in time, such as immediately following an intervention.  This therefore does not allow for the continuous assessment of workload over time and it is here that objective measures can be more useful.  Electroencephalography (EEG) is an example of such an objective measure and it is suitable to use in an educational setting as it can measure brain activity in a sensitive but non-invasive manner. 

The continuous EEG signal is made up of oscillations in various frequencies (Antonenko et al., 2010), with the five main frequency bands from lowest to highest being delta (0.1-3.9Hz), theta (4.0-7.9Hz), alpha (8.0-12.9Hz), beta (13-29.9Hz) and gamma (30-100Hz) (summarised by Kumar and Kumar (2016)).  Of these, early studies have reported the theta and alpha bands to be indicative of memory and cognitive performance (Gerě & Jaušovec, 1999; Klimesch, 1999), with later studies showing that these bands are important in working memory processes (Jaušovec & Jaušovec, 2012; Maurer et al., 2015).  The theta band is proportional to cognitive load and is most prominent in frontal brain regions, while the alpha band is inversely proportional and is most prominent in posterior brain regions (Gevins et al., 1998; Klimesch, 1999; Gevins & Smith, 2003; Klimesch et al., 2005; Sauseng et al., 2005; Holm et al., 2009), although some studies have also reported increases in the alpha band with increasing working memory load (Jensen et al., 2002) as well as differences among individuals (Michels et al., 2008).  In an educational context, Dan and Reiner (2017) used EEG to compare the cognitive load experienced while learning origami in 2D and 3D learning environments and Makransky et al. (2019) compared the cognitive load experienced for highly immersive head-mounted display (HMD) and less immersive desktop deliveries of a virtual reality (VR) biology simulation.  While the Kucuk et al. (2016), Foo et al. (2013), Dan and Reiner (2017) and Makransky et al. (2019) studies used only either subjective or objective measures of cognitive load in their comparisons of different educational methods, none of them used both measures.  EEG and the NASA-TLX have been used together in other studies outside of education to measure cognitive load in pilots while performing scenarios of increasing difficulty (Gentili et al., 2014) and in surgeons during different surgical procedures and exercises (Guru et al., 2015; Morales et al., 2019), although there is a need to apply this in anatomy education.  Additionally, the Guru et al. (2015) study evaluated the performance of only one surgeon and the other studies mentioned only included participants from a single cohort, notably students with minimal prior knowledge (Foo et al., 2013; Kucuk et al., 2016; Makransky et al., 2019). 

Given the shift that has occurred over time in anatomy education away from a predominantly dissection-based approach due to practical, financial and ethical concerns (Chien et al., 2010; Thomas et al., 2010; Kamphuis et al., 2014), as well as the limitations associated with resources such as anatomical models, textbooks and atlases that have been noted in the literature (Nieder et al., 2000; Luursema et al., 2006; Nicholson et al., 2006; Yeom, 2011; Ma et al., 2016), technology has become a large part of delivering anatomy content.  As such, an increasingly important aspect of instructional design in anatomy is developing technology-based resources and cognitive learning theories can serve as a useful foundation for this.  One that is particularly relevant is Richard Mayer’s cognitive theory of multimedia learning (CTML) (Mayer, 2009, 2014), which was developed from several other theories including CLT.  Sorden (2012) explains that the CTML is based on three assumptions – firstly, working memory has two channels through which to receive information, auditory and visual; secondly, similar to CLT, working memory has a limited capacity; and thirdly, people engage in meaningful learning when they focus on the material to be learnt, mentally organise it and then integrate it with prior knowledge.  The theory provides 12 principles for the design of multimedia resources, with multimedia being defined as the combination of words, which can be either written or spoken, and pictures, which can be in various graphical forms including drawings, photos, animations and videos (Sorden, 2012).  At the centre of the theory is the “multimedia principle”, which states that people learn more deeply from this combination than from words alone (Mayer, 2009).  The 12 principles in the CTML are organised around three types of cognitive processing and these are synonymous with the three components of cognitive load in CLT – essential processing (synonymous with intrinsic load), which results from the complexity of the material; extraneous processing (synonymous with extraneous load), which results from distractions or poor delivery of information; and generative processing (synonymous with germane load), which results from the learner's motivation to make sense of the information (Sorden, 2012).  Therefore, similar to CLT, through these 12 principles the CTML is concerned with aiming to manage essential processing, reduce extraneous processing and foster generative processing (Mayer, 2009).   

Makransky et al. (2019) investigated whether the “redundancy principle” of the CTML, which states that people learn better from graphics and narration than from graphics, narration and printed text (Mayer, 2009), was applicable to VR.  They found that overall there was no major effect of the redundancy principle, although this could be because they compared the combination of text and narration to text alone rather than narration alone, which would have aligned more closely with the redundancy principle.  Nonetheless, they express the need to develop guidelines for the design of learning resources with immersive technologies.  Moreno and Mayer (2007) have explored this by extending the CTML to technologies such as VR and proposing five principles that can be applied when designing interactive multimodal resources using such technologies.  However, these principles are very similar to those in the CTML, meaning that evidence-based guidelines specific to VLRs are still limited in this field.  A review conducted by Zhu et al. (2014) on the use of AR in healthcare education highlights that there is little evidence to guide the instructional design of AR resources and therefore proposed a potential design framework for this purpose (Zhu et al., 2015).  However, this was developed specifically to guide the design of mobile AR apps and was applied only in the context of educating doctors on informed antibiotic prescription.  The ADDIE (analysis, design, development, implementation, evaluation) instructional design framework (Peterson, 2003) was applied by Codd and Choudhury (2011) in the development of a VR anatomy resource with positive results, although ADDIE is a general instructional design framework and is not specifically catered to the design of VLRs. 

If VLRs are going to be increasingly adopted in anatomy education, it is important that their design promotes effective learning.  Therefore, the overarching aim of this study was to propose guidelines for the instructional design of VLRs for anatomy education.  In order to ground these guidelines within CLT and the CTML, however, the immediate aim of the study was to compare the cognitive load experienced for highly immersive and less immersive VLR deliveries using both objective and subjective measures, as well as evaluate the impact of (a) prior anatomy knowledge and (b) prior university experience on the cognitive load experienced. 

Aims/Outcomes 

Aim 1: to compare the effectiveness of high-fidelity (HF) and low-fidelity (LF) VLRs for learning anatomy.   

Aim 2: to compare the cognitive load experienced for highly immersive and less immersive delivery modes of virtual reality deliveries using both objective and subjective measures, as well as evaluate the impact of (a) prior anatomy knowledge and (b) prior university experience on the cognitive load experienced. 

Aim 2: To develop a remote learning virtual laboratory experience for Anatomy Education at UNSW 

Progress / Outcomes  

Outcomes of Aim 1:  

Progress:  Evidence-based Study: 

HF and LF VLRs were developed for liver anatomy and participants were voluntarily recruited from two cohorts, those without (cohort 1) and with (cohort 2) prior anatomy knowledge, to compare them (UNSW Sydney Ethics #HC16592).  Knowledge outcomes was measured through pre- and post-tests, task outcomes including activity score and completion time were recorded and participants’ perceptions were surveyed.  A total of 333 participants (165 HF, 168 LF) took part in this study.  Knowledge outcomes were higher for the HF activity in cohort 1 and for the LF activity in cohort 2, although not significantly.  There were no significant differences in activity score within either cohort, although completion time was significantly longer for the HF activity in cohort 1 (P=0.001).  There were no significant differences within either cohort in perceptions regarding revision, aesthetics, quality or mental effort or in perceptions regarding future use of the VLRs, although the LF VLR was scored significantly higher for understanding in cohort 1 (P=0.027).  This study suggests that high physical fidelity is not necessarily required for anatomy VLRs, although may potentially be valuable for improving knowledge outcomes.  Also, level of prior knowledge may be an important factor when considering the physical fidelity of anatomy VLRs. 

Outcomes of Aim 2:  

Progress:  Evidence-based Study: 

Participants were voluntarily recruited to experience stereoscopic and desktop deliveries of VLRs (UNSW Sydney Ethics #HC16592).  The VLR was delivered using two different modalities – a highly immersive stereoscopic projection-based system and a less immersive desktop system, both of which have been described in our previous work (Birbara et al., 2020).  To briefly summarise, the stereoscopic delivery was achieved using the AVIE 360-degree stereoscopic immersive interactive visualisation system located in the iCinema Centre for Interactive Cinema Research at UNSW Sydney (McGinity et al., 2007), and an XBox® controller (Microsoft, Redmond, WA) was used to navigate through the VLR.  The desktop delivery took place in a computer laboratory and a standard mouse and keyboard were used to navigate through the VLR. A MyndBand® electroencephalography (EEG) headset was used to collect brainwave data and theta power was used as an objective cognitive load measure.  The National Aeronautics and Space Administration task load index (NASA-TLX) was used to collect perceptions as a subjective measure.  Both objective and subjective cognitive load measures were higher overall for the stereoscopic delivery and for participants with prior knowledge, and significantly higher for junior students (P=0.038).  Based on this study’s results, those of several of our previous studies and the literature, various factors are important to consider in VLR design.  These include delivery modality, their application to collaborative learning, physical fidelity, prior knowledge and prior university experience.  Overall, the guidelines proposed based on these factors suggest that VLR design should be learner-centred and aim to reduce extraneous cognitive load. 

Progress: Guidelines for the instructional design of virtual learning resources 

Based on this study’s immediate results, the results of our previous work and the literature, several factors to consider in the instructional design of VLRs for anatomy education have been discussed.  Collectively, these can be considered in light of CLT and the CTML and collated to propose guidelines for anatomy VLR design.  The guidelines can be organised according to their focus on the presentation of the learning content, the characteristics of the learners receiving the content, and the delivery of the content to create the learning environment.  A summary of the guidelines is presented in Figure 1, below.   

In the design of educational tools, the learning objective(s) to be addressed is one of the main considerations, as this can inform the presentation of the learning content.  For medicine VLRs this can relate to physical fidelity, which gives rise to the first guideline: 

1. Physical fidelity: Focusing on a specific learning objective for VLRs can inform the incorporation of physical fidelity.  If the purpose of the VLR is to demonstrate anatomical relations or orientation then high physical resemblance may not be required, while if it is intended for learners to be able to identify and differentiate between structures then physical resemblance may be useful. 

The characteristics of the target learners is another main consideration to account for in VLR design.  In general, VLRs can be more beneficial for those with prior knowledge and/or university experience.  However, they can still be designed to suit the needs of novice learners, which gives rise to the second guideline: 

2. The novice learner: For learners with minimal prior knowledge and university experience, particularly the former, VLR experiences that are less immersive and/or novel but still stereoscopic can be most appropriate.  They should also provide a more guided learning experience where the pace of that guidance can be controlled and the overall length of the experience is minimised.  Regarding the incorporation of physical fidelity, the association of high-fidelity VLRs with traditional anatomy classes can be particularly important for these learners. 

Not only is it important to consider characteristics such as prior knowledge in VLR design, but also learners in general and how the learning environment can provide the most effective learning experience.  This gives rise to the remaining four guidelines: 

3. Immersion: Less immersive deliveries (e.g. desktop) can be favourable to reduce the degree of mental effort experienced, by imposing less extraneous load/requiring less extraneous processing.  They can also reduce the disorientation and physical discomfort associated with more immersive modalities. 

4. Stereoscopy: For stereoscopy to be used effectively, a less immersive delivery (e.g. desktop) can be more appropriate and the motion of the virtual content should be restricted, so as not to impose excessive extraneous load/require excessive extraneous processing.  

5. User control: A degree of user control can be beneficial, particularly when the delivery modality is more immersive and when the virtual content is dynamic.  However, adequate training and time for familiarisation is necessary for this to provide optimal benefits. 

6. Collaboration: For face-to-face collaborative learning, a tactile interface can encourage dynamic interaction through natural non-verbal communication.  Delivery modalities which allow for simultaneous viewing of virtual content and the real world can also be the most appropriate to facilitate non-verbal communication.  Additionally, the incorporation of immediate feedback can promote more involvement of learners in the collaborative process. 

Overall, the immediate results of this study support our previous work and these collective findings have been collated to propose guidelines for the instructional design of anatomy VLRs.  These can be summarised as relating to learning content presentation (“physical fidelity” guideline), learner characteristics (“the novice learner” guideline) and the learning environment (“immersion”, “stereoscopy”, “user control” and “collaboration” guidelines).  Sorden (2012) highlights that the principles of multimedia design in the CTML are learner-centred rather than technology-centred.  Similarly, the guidelines proposed in this study are learner- and learning-centred and have been grounded within cognitive learning theories.  While the factors they are based on have been considered in terms of the unique characteristics and capabilities of immersive technologies, they are not intended to be technology-centred.  Rather, they ensure that these characteristics and capabilities can be utilised in a learner-centred fashion.  This is extremely important when designing not only multimedia resources in general but especially VLRs, as the very nature of immersive technologies can easily introduce distraction which detracts from the educational purpose of VLRs.  Collectively, the proposed guidelines incorporate factors for VLR design which aim to reduce extraneous load/extraneous processing and consequently foster germane load/generative processing to ensure that VLRs can be used effectively for learning. 

Outcomes of Aim 3:  

A framework for Anatomy Virtual Immersive Experience has been develop and is being implemented for medical education. We have shared our framework with both national and international medical education bodies.   The Virtual Immersive Experience simulates an anatomy laboratory and includes fully interactive visual resources. This is being developed in collaboration with the University of British Columbia, Canada.  This will be deployed to UNSW undergraduate students in T1, 2021. 

Figure 2: Example of fully interactive virtual models for medical education. These will be placed in a virtual simulation of an anatomy laboratory created on Unity. Students will be able to select their course and week, and then ‘walk’ into the lab where they will find the learning resources laid out on the laboratory tables for them to access. An avatar will guide them through the learning activities and provide them with helpful links to video resources as well as formative assessment activities. 

Dissemination of this work: 

• accepted for publication and is in press:   

• Birbara NS and Pather N. 2021. Instructional design of virtual learning resources for anatomy education. In: Rea PM (Editor). Biomedical Visualisation [in press] 

• Birbara NS, Pather N. 2020. Real or not real: The impact of the physical fidelity of virtual learning resources on learning. Anat Sci Educ [early view]. 

• presented at conference:  

• Real or not real: The impact of physical fidelity on learning anatomy in an interactive labelling task. Poster presentation, ANZAHPE conference, Canberra, ACT, Australia, 1-4 July 2019. 

• Factors to consider in the instructional design of virtual learning resources for anatomy education. Oral presentation, ANZACA conference, Perth, WA, Australia, 4-6 December 2019. 

• Factors to consider in the instructional design of virtual learning resources for anatomy education. Oral presentation, ANZACA conference, Perth, WA, Australia, 4-6 December 2019. 

Future directions 

The comparison of cognitive load in this study between a highly immersive projection-based and a less immersive desktop VLR delivery could also be extended to fully immersive HMDs.  Makransky et al. (2019) compared cognitive load for HMD and desktop deliveries of a VR biology simulation, although a comparison of all three of these delivery modalities would be interesting.  In the context of medical education, different VLR deliveries could also be compared to traditional learning experiences in relation to cognitive load.  Another future direction could be to extend further from the combination of objective and subjective cognitive load measures and compare EEG to other potential objective measures such as heart rate, pupil response and eye movements (e.g. blinking).  Furthermore, considering the guidelines proposed in this study for the instructional design of anatomy VLRs, these could be applied and tested to determine their usefulness in the development of effective VLRs. 

Acknowledgements: 

We would like to acknowledge and thank: 

• Claude Sammut, Alex Ong, Nicola Best and Andrew Yip from the iCinema Centre for Interactive Cinema Research; and for their assistance with the VLRs in our previous studies,  

• Tomasz Bednarz, Robert Lawther, Dominic Branchaud and Daniel Filonik from the Expanded Perception & Interaction Centre (EPICentre), 

• Luis (Carlos) Dominguez, Kaveh Tabar Heydar and Xueqing (Sherry) Lu from the Immersive Technologies Educational Design and Development group, 

• Zhixin Liu from the Stats Central unit in the UNSW Sydney Mark Wainwright Analytical Centre for assisting with the statistical analysis in this study 

References 

• Birbara NS; Sammut C; Pather N, 2020, 'Virtual Reality in Anatomy: A Pilot Study Evaluating Different Delivery Modalities', Anatomical Sciences Education, vol. 13, pp. 445-457   

 http://dx.doi.org/10.1002/ase.1921 

• Birbara NS, Pather N. 2020. Real or not real: The impact of the physical fidelity of virtual learning resources on learning. Anatomical Sciences Education [early view]  

http://dx.doi.org/10.1002/ase.2022 

• Birbara NS and Pather N. 2021. Instructional design of virtual learning resources for anatomy education. In: Rea PM (Editor). Biomedical Visualisation [in press] 

• Djokic T., Marcus N., Oliver C., Pather N., Sammut C., Kenderdine S., and Yip A. Designing multi-disciplinary immersive learning systems for next generation student experiences: case studies and future directions in astrobiology, anatomy and cultural heritage. [in press] 

 

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Title: Transforming Educational Practice: An International multi-disciplinary collaboration

Introduction 

In 2019-2020, I engaged in several projects that facilitated transforming anatomy education and the development of professional learning communities. Significantly, in 2019 I was appointed to Chair an International Education Program for Anatomical Education (FIPAE) for the IFAA which is the peak body representing anatomical associations in 55 countries that enabled engagement with medical education learning communities internationally.   

Even before the COVID-19 pandemic, higher education was being significantly reshaped by students lived experiences and as well as a plethora of educational technology. The almost overnight pivot to remote delivery in March 2020 brought on by the pandemic, while accelerating change, also exposed a need for evidence-based digital pedagogies and resources, and highlighted areas in which professional development is essential.   

I engaged in the following initiatives to support the development of higher education academy: 

• Supported the development of an international community of educators responding to educational challenges including a pivot to remote delivery in 2020 

• Developed resources responding to innovative and immediate educational pedagogies  

• Developed and implemented a framework for supporting early career anatomy academics in transitioning into academic roles via skills and community development 

Aims 

The overarching aim is to develop an international learning community supporting academics through skills and resource development as well as mentoring in order to further anatomical sciences education.  

The specific immediate aims are: 

Aim 1: Support the development of an international community of educators developing skills in dual/hybrid/remote educational delivery 

Aim 2: Develop evidence-based resources to respond to innovative educational pedagogies  

Aim 3: Develop equitable frameworks and programs to support early career academics in transitioning into academia 

Progress / Outcomes / Next steps 

Aim 1: Support the development of an international community of educators developing skills in dual/hybrid/remote educational delivery  

Example 1: Accelerated to Remote Learning of Anatomy Education in Australia and New Zealand 

Australian and New Zealand universities commenced a new academic year in February/March 2020 largely with “business as usual.” The subsequent Covid‐19 pandemic imposed unexpected disruptions to anatomical educational practice. Rapid change occurred due to government‐imposed physical distancing regulations from March 2020 that increasingly restricted anatomy laboratory teaching practices. Anatomy educators in both these countries were mobilized to adjust their teaching approaches. This study aimed to collate and share the responses at local institutions to develop a shared and unified discipline response within Australia and New Zealand. The study therefore adopted a social constructivist lens. The research question was “What are the perceived disruptions and changes made to anatomy education in Australia and New Zealand during the initial period of the Covid‐19 pandemic, as reflected on by anatomy educators?.” Thematic analysis to elucidate “the what and why” of anatomy education was applied to these reflections. About 18 anatomy academics from ten institutions participated in this exercise. The analysis revealed loss of integrated “hands‐on” experiences, and impacts on workload, traditional roles, students, pedagogy, and anatomists' personal educational philosophies. The key opportunities recognized for anatomy education included: enabling synchronous teaching across remote sites, expanding offerings into the remote learning space, and embracing new pedagogies. In managing anatomy education's transition in response to the pandemic, six critical elements for anatomy leaders were identified: community care, clear communications, clarified expectations, constructive alignment, community of practice, ability to compromise, and adapt and continuity planning. The collated responses were shared within Australia and New Zealand and with other countries. Of note, it was instrument in informing a unified approach in the UK; and has developed stronger links for Australia and NZ in collaboration on remote delivery with UK and Canada.   

Example 2: Developing an International Community for Anatomical Education 

In response the changes in higher education brought on by COVID-19, and the aim to develop a connected learning community, I organised and launched the Virtual Anatomy Education Symposium Series. The inaugural Virtual International Anatomy Education Symposia was on 15 October 2020. This was a unique opportunity to engage anatomists across the globe. 

The symposium consisted of two keynote talks and a panel discussion: 

• Keynote 1. Professor Gareth Jones (Otago University, New Zealand): COVID-19 and anatomy: Threats to the continued flourishing of anatomy as a humanistic and research-based discipline 

• Keynote 2. Professor Claudia Krebs (UBC, Canada): The Virtual Anatomy Lab: creation and implementation during the COVID-19 pandemic. 

• Panel Discussion. Opportunities and Challenges to Anatomy Education. Panel members: Professor Beverley Kramer, Professor Adam Taylor, Professor Andrea Oxley da Rocha, Ms Joyce El-Haddad (Chair, Professor Nalini Pather) 

The recording of the symposium is found at https://www.ifaa.net/education/ It continues to be accessed with high frequency.  A total of 1104 participants registered for the symposium (111 of these were for the recording only) from 33 countries.  On the day, there were 1342 in attendance (643 via Zoom and the remainder via the livestream).  

A further skills and training event is scheduled for 2020. This is a training workshop on Quality Qualitative Research in Anatomy. This workshop will focus on the basic principles underlying qualitative research, as well as an opportunity to undertake some steps involved with qualitative analysis.   The workshop will be conducted in association with AAA, ANZACA, AMEE, IAMSE and AAMC.  

Aim 2: Develop evidence-based response to innovative educational pedagogies 

Example 1: Spending Wisely: The Role of Cost and Value Research in the Pursuit of Advancing Anatomical Sciences Education (in collaboration with Monash University) 

Studies of “cost and value” in anatomical sciences education examine not only what works, but at what cost, thus evaluating the inputs and outputs of education. This collaboration provides insights into how to use available resources (e.g., academic time, budgets, infrastructure) as a mechanism to obtaining the maximum outcomes available. The purpose of this discourse is to expand on the application of cost and value concepts to anatomical sciences education, contextualizing these concepts through a deeper dive into the more costly educational approaches of human donor dissection. In doing so, both questions and opportunities are raised for the discipline of anatomical sciences going forward. Educational decisions, inclusive of cost and value appraisals, consider the range of outcomes for which the activity is designed to achieve, and the activity's integration with the philosophy of the educational program it is contributing to; these decisions, thus, evaluate more than just cost alone. Healthcare students' engagement with human donor dissection pedagogy offers an array of reported non‐economic benefits, including non‐traditional discipline‐independent skill (NDIS) development (e.g., professionalism, teamwork skills). These skills are often harder to measure, but are no less important to the final pedagogical decision‐making process. The goal of cost and value research is to create an evidence‐base toward education that delivers maximum value for a given spend. Anatomy educators, researchers, and decision makers who embrace cost and value dialogue, and interpret and apply findings from studies of educational costs, are best positioned to improve the educational value for their learners and provide effective outputs for all stakeholders. 

Example 2: Beyond the Sex Binary: Toward the Inclusive Anatomical Sciences Education (in collaboration with A.Prof. Goran Strkalj, UNSW) 

Developments in biology and genetics in recent decades have caused significant shifts in the understanding and conceptualization of human biological variation. Humans vary biologically in different ways, including individually, due to age, ancestry, and sex. An understanding of the complexities of all levels of biological variation is necessary for efficient health care delivery. Important steps in teaching medical students about human variation could be carried out in anatomy classes, and thus, it is important that anatomical education absorbs new developments in how biological variation is comprehended. Since the early 1990s biological sex in humans has been vigorously investigated by scientists, social scientists, and interest groups. Consequently, the binary division in male and female sex has been called into question and a more fluid understanding of sex has been proposed. Some of the major textbooks teach anatomy, particularly of the urogenital system, as a male‐female binary. Anatomical sciences curricula need to adopt a more current approach to sex including the introduction of the category of “intersex”/“differences in sexual development” and present sex as a continuum rather than two sharply divided sets of characteristics. This approach offers a better understanding of the complexity of sex differences and, at the same time, provides students with an improved theoretical framework for understanding human variation in general, transcending the limitations of biological typology. When well delivered, the non‐binary approach could play a significant contribution to the formation of competent and responsible medical practitioners and avoidance of problematic practices such as non‐consensual “normalizing” surgeries. 

Example 3: Support cross-disciplinary frameworks to develop core syllabus in health sciences education (in collaboration with Rosemary Guiriato, Macquarie University; Raymond Blaich, Southern Cross University; Goran Strkalj, UNSW) 

Human anatomy education is compulsory in the health professional programs. There is a paucity of information relating to anatomy content and delivery in health programs. Previous research exploring professional anatomy education within health programs confirmed considerable investment in anatomy teaching resources but provided little insight into the usefulness and effectiveness of these teaching tools. Relevance of education to clinical practice is one of the most important aspects of teaching and learning. To date, there exists little information on the relevance and adequacy of anatomy education in health programs to clinical practice.  There is also very little data on what the core requirements of the anatomy program for each professional health program.  Clinicians are uniquely able to offer input on anatomical sciences education as they are at the forefront of both the theoretical application of knowledge to clinical practice and of changes to the practice of the profession. The aims of this initiative is to determine from multiple perspectives the core requirement for anatomy education in each health program, benchmarking across different countries, and to determine the current relevance and adequacy of anatomy training for clinical practice. Multiple dimensions are analysed to determine a core syllabus including Delphi consensus, perceptions of students and clinicians, as well as student experience in each program. 

Example 4: A framework for Immersive Educational Design (in collaboration with Nicolette Birbara, UNSW) 

Please see separate report on Immersive Technologies. 

Aim 3: Develop equitable frameworks and programs to support early career academics in transitioning into academia (in collaboration with Beverley Kramer, Wits University South Africa and the IFAA) 

Example 1: Assessing the needs of early career anatomy academics 

The formative years in academia are difficult for early career academics as they transition into their new roles in teaching and research. Ubiquitous changes in health sciences education have compounded this transition for early career anatomists (ECA), who must balance curriculum transformations, research imperatives and administrative responsibilities as they navigate their transition. Support for ECAs is thus important in order to provide a strong pipeline of anatomists for the future of the discipline and its foundational role in the health sciences.  In 2019, an initial international study was conducted to investigate the needs of international ECAs with respect to teaching, research and career/professional development in the anatomical sciences. Data gathered included ECAs level of academic appointment, training for education delivery and nature of support that ECAs may find valuable for their development. Over 590 respondents from across the globe answered the survey. Requests for training in the clinical relevance and application of anatomical sub-disciplines were frequent. Importantly, support to establish collaborations, mentorship relationships and professional networks were repeatedly requested. In this first ever international survey of ECAs, the needs expressed by respondents indicate the importance of academic and professional development support at both local and global levels. Partnerships between the IFAA, institutions, anatomical and educational associations should create training and mentoring opportunities to smooth the transition into academia for these young academics, which would ensure the future of the discipline and its role in the health sciences.   

Importantly, the need for professional networks and communities of practice as well as mentorship was identified as urgent needs and informed the development of the 2020 program. 

Publications 

• Pather N; Blyth P; Chapman JA; Dayal MR; Flack NAMS; Fogg QA; Green RA; Hulme AK; Johnson IP; Meyer AJ; Morley JW; Shortland PJ; Štrkalj G; Štrkalj M; Valter K; Webb AL; Woodley SJ; Lazarus MD, 2020, 'Forced Disruption of Anatomy Education in Australia and New Zealand: An Acute Response to the Covid-19 Pandemic', Anatomical Sciences Education, vol. 13, pp. 284 - 300,  

• Kramer B; Hartmann C; Toit FD; Hutchinson E; Pather N, 2020, 'Supporting early career anatomists: An international challenge', Annals of Anatomy - Anatomischer Anzeiger, pp. 151520 - 151520, http://dx.doi.org/10.1016/j.aanat.2020.151520 

• Maloney S; Pather N; Foo J; Lazarus MD, 2020, 'Spending Wisely: The Role of Cost and Value Research in the Pursuit of Advancing Education Anatomical Sciences Education (in press)  

• Štrkalj G; Pather N, 2020, 'Beyond the Sex Binary: Toward the Inclusive Anatomical Sciences Education', Anatomical Sciences Education, http://dx.doi.org/10.1002/ase.2002 

• Giuriato R; Štrkalj G; Meyer AJ; Pather N, 2020, 'Anatomical Sciences in Chiropractic Education: A Survey of Chiropractic Programs in Australia', Anatomical Sciences Education, vol. 13, pp. 37 - 4  

• Hutchinson EF; Kramer B; Billings BK; Brits DM; Pather N, 2020, 'The Law, Ethics and Body Donation: A Tale of Two Bequeathal Programs', Anatomical Sciences Education, vol. 13, pp. 512 - 519  

• Giuriato R., Strkalj G., Meyer A., Pather N. (under review). Clinicians perceptions on the Relevance of Curriculum to Chiropractic Practice.

UNSW level contributions

• UNSW Scientia Education Academy